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<h1 class="p_Heading1"><span class="f_Heading1">HIV Care Static Form: Enrollment</span></h1>
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<p>&nbsp;</p>
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<td colspan="3" style="vertical-align:top; height:17px; background-color:#c0c0c0; padding:4px; border:solid 1px #000000;"><p><span style="font-weight: bold;">Enrollment Form Business Rules</span></p>
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<td style="vertical-align:top; width:90px; height:17px; background-color:#c0c0c0; padding:4px; border:solid 1px #000000;"><p> </p>
</td>
<td style="vertical-align:top; width:217px; height:17px; background-color:#c0c0c0; padding:4px; border:solid 1px #000000;"><p> </p>
</td>
<td style="vertical-align:top; width:83px; height:17px; background-color:#c0c0c0; padding:4px; border:solid 1px #000000;"><p> </p>
</td>
<td style="vertical-align:top; width:83px; height:17px; background-color:#c0c0c0; padding:4px; border:solid 1px #000000;"><p> </p>
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<td style="vertical-align:top; width:71px; height:17px; background-color:#c0c0c0; padding:4px; border:solid 1px #000000;"><p> </p>
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<td style="vertical-align:top; width:65px; height:17px; background-color:#c0c0c0; padding:4px; border:solid 1px #000000;"><p> </p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:51px; height:18px; padding:4px; border:solid 1px #000000;"><br />
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<td style="vertical-align:top; width:71px; height:18px; padding:4px; border:solid 1px #000000;"><br />
</td>
<td style="vertical-align:top; width:106px; height:18px; padding:4px; border:solid 1px #000000;"><br />
</td>
<td style="vertical-align:top; width:90px; height:18px; padding:4px; border:solid 1px #000000;"><br />
</td>
<td style="vertical-align:top; width:217px; height:18px; padding:4px; border:solid 1px #000000;"><br />
</td>
<td style="vertical-align:top; width:83px; height:18px; padding:4px; border:solid 1px #000000;"><br />
</td>
<td style="vertical-align:top; width:83px; height:18px; padding:4px; border:solid 1px #000000;"><br />
</td>
<td style="vertical-align:top; width:71px; height:18px; padding:4px; border:solid 1px #000000;"><br />
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<td style="vertical-align:top; width:65px; height:18px; padding:4px; border:solid 1px #000000;"><br />
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<td style="vertical-align:top; width:51px; height:26px; background-color:#c0c0c0; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt; font-weight: bold;">Form No.</span></p>
</td>
<td style="vertical-align:top; width:71px; height:26px; background-color:#c0c0c0; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt; font-weight: bold;">Form Label</span></p>
</td>
<td style="vertical-align:top; width:106px; height:26px; background-color:#c0c0c0; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt; font-weight: bold;">Database Table</span></p>
</td>
<td style="vertical-align:top; width:90px; height:26px; background-color:#c0c0c0; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt; font-weight: bold;">Field Name</span></p>
</td>
<td style="vertical-align:top; width:217px; height:26px; background-color:#c0c0c0; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt; font-weight: bold;">Business Rule</span></p>
</td>
<td style="vertical-align:top; width:83px; height:26px; background-color:#c0c0c0; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt; font-weight: bold;">De-identified Field</span></p>
</td>
<td style="vertical-align:top; width:83px; height:26px; background-color:#c0c0c0; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt; font-weight: bold;">Required for Saving</span></p>
</td>
<td style="vertical-align:top; width:71px; height:26px; background-color:#c0c0c0; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt; font-weight: bold;">Minimum Reporting</span></p>
</td>
<td style="vertical-align:top; width:65px; height:26px; background-color:#c0c0c0; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt; font-weight: bold;">Minimum Clinical</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:51px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">1</span></p>
</td>
<td style="vertical-align:top; width:71px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">First Name</span></p>
</td>
<td style="vertical-align:top; width:106px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">mst_Patient </span></p>
</td>
<td style="vertical-align:top; width:90px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">FirstName</span></p>
</td>
<td style="vertical-align:top; width:217px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:83px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">Yes</span></p>
</td>
<td style="vertical-align:top; width:83px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">Yes</span></p>
</td>
<td style="vertical-align:top; width:71px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">Yes</span></p>
</td>
<td style="vertical-align:top; width:65px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">Yes</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:51px; height:45px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">1</span></p>
</td>
<td style="vertical-align:top; width:71px; height:45px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">Last Name</span></p>
</td>
<td style="vertical-align:top; width:106px; height:45px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">mst_Patient </span></p>
</td>
<td style="vertical-align:top; width:90px; height:45px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">LastName</span></p>
</td>
<td style="vertical-align:top; width:217px; height:45px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">Alert the User if the System already has a patient with the entered last name.</span></p>
</td>
<td style="vertical-align:top; width:83px; height:45px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">Yes</span></p>
</td>
<td style="vertical-align:top; width:83px; height:45px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">Yes</span></p>
</td>
<td style="vertical-align:top; width:71px; height:45px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">Yes</span></p>
</td>
<td style="vertical-align:top; width:65px; height:45px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">Yes</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:51px; height:113px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">2</span></p>
</td>
<td style="vertical-align:top; width:71px; height:113px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">Visit Date</span></p>
</td>
<td style="vertical-align:top; width:106px; height:113px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">ord_Visit </span></p>
</td>
<td style="vertical-align:top; width:90px; height:113px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">VisitDate</span></p>
</td>
<td style="vertical-align:top; width:217px; height:113px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">Date on which the patient came into the clinic.</span><br />
<span style="font-size: 8pt;">No future dates allowed. No default required (ie don't default to today's date, leave blank. Because the forms get filled in the following day or later, the data entry person would have to change the date in any case.)</span></p>
</td>
<td style="vertical-align:top; width:83px; height:113px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:83px; height:113px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">Yes</span></p>
</td>
<td style="vertical-align:top; width:71px; height:113px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">Yes</span></p>
</td>
<td style="vertical-align:top; width:65px; height:113px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">Yes</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:51px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">3</span></p>
</td>
<td style="vertical-align:top; width:71px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">ID - Country</span></p>
</td>
<td style="vertical-align:top; width:106px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">mst_Facility </span></p>
</td>
<td style="vertical-align:top; width:90px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">CountryID</span></p>
</td>
<td style="vertical-align:top; width:217px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">Auto filled for all forms - driven by the software set up</span></p>
</td>
<td style="vertical-align:top; width:83px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:83px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">Yes</span></p>
</td>
<td style="vertical-align:top; width:71px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">Yes</span></p>
</td>
<td style="vertical-align:top; width:65px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:51px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">3</span></p>
</td>
<td style="vertical-align:top; width:71px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">ID - LPTF#</span></p>
</td>
<td style="vertical-align:top; width:106px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">mst_Facility </span></p>
</td>
<td style="vertical-align:top; width:90px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">PosID</span></p>
</td>
<td style="vertical-align:top; width:217px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">Auto filled for all forms - driven by the software set up</span></p>
</td>
<td style="vertical-align:top; width:83px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:83px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">Yes</span></p>
</td>
<td style="vertical-align:top; width:71px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">Yes</span></p>
</td>
<td style="vertical-align:top; width:65px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:51px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">3</span></p>
</td>
<td style="vertical-align:top; width:71px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">ID - Satellite #</span></p>
</td>
<td style="vertical-align:top; width:106px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">mst_Facility </span></p>
</td>
<td style="vertical-align:top; width:90px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">SatelliteID</span></p>
</td>
<td style="vertical-align:top; width:217px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">Auto filled for all forms - driven by the software set up</span></p>
</td>
<td style="vertical-align:top; width:83px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:83px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">Yes</span></p>
</td>
<td style="vertical-align:top; width:71px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">Yes</span></p>
</td>
<td style="vertical-align:top; width:65px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:51px; height:180px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">3</span></p>
</td>
<td style="vertical-align:top; width:71px; height:180px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">ID - Patient Enrollment Number</span></p>
</td>
<td style="vertical-align:top; width:106px; height:180px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">mst_Patient </span></p>
</td>
<td style="vertical-align:top; width:90px; height:180px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">PatientEnrollmentID</span></p>
</td>
<td style="vertical-align:top; width:217px; height:180px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">This is the ID for the patient who enters into the AIDSRelief program</span><br />
<span style="font-size: 8pt;">Country, POS#, Satelite# are pre-set upon software configuration and pre-pends the Patient Enrollment number.</span><br />
<span style="font-size: 8pt;">The enrollment form is the only location this field is filled in for the patient.</span><br />
<span style="font-size: 8pt;">&nbsp;</span><br />
<span style="font-size: 8pt;">Once saved, then this field should not be editable, except by Users who have editing rights (as specified in a User Group).</span></p>
</td>
<td style="vertical-align:top; width:83px; height:180px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:83px; height:180px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">Yes</span></p>
</td>
<td style="vertical-align:top; width:71px; height:180px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">Yes</span></p>
</td>
<td style="vertical-align:top; width:65px; height:180px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
</tr>
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<td style="vertical-align:top; width:51px; height:135px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">4</span></p>
</td>
<td style="vertical-align:top; width:71px; height:135px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">Existing Hosp/Clinic #</span></p>
</td>
<td style="vertical-align:top; width:106px; height:135px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">mst_Patient </span></p>
</td>
<td style="vertical-align:top; width:90px; height:135px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">PatientClinicID</span></p>
</td>
<td style="vertical-align:top; width:217px; height:135px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">Patient registration number for the clinic. This may or may not be available for the patient.</span><br />
<span style="font-size: 8pt;">This is can be alpha numberic. </span><br />
<span style="font-size: 8pt;">This is unique for a facility. </span><br />
<span style="font-size: 8pt;">The system will check for duplicates.</span><br />
<span style="font-size: 8pt;">The enrollment form is the only location this field is filled in for the patient.</span><br />
<span style="font-size: 8pt;">This is an editable field.</span></p>
</td>
<td style="vertical-align:top; width:83px; height:135px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:83px; height:135px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:71px; height:135px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:65px; height:135px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">Yes</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:51px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">5</span></p>
</td>
<td style="vertical-align:top; width:71px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">Sex</span></p>
</td>
<td style="vertical-align:top; width:106px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">mst_Patient </span></p>
</td>
<td style="vertical-align:top; width:90px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">Sex</span></p>
</td>
<td style="vertical-align:top; width:217px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">Gender (sex) F= Female M= Male</span><br />
<span style="font-size: 8pt;">This is an editable field.</span></p>
</td>
<td style="vertical-align:top; width:83px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:83px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">Yes</span></p>
</td>
<td style="vertical-align:top; width:71px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">Yes</span></p>
</td>
<td style="vertical-align:top; width:65px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">Yes</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:51px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">7</span></p>
</td>
<td style="vertical-align:top; width:71px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">Date of Birth</span></p>
</td>
<td style="vertical-align:top; width:106px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">mst_Patient </span></p>
</td>
<td style="vertical-align:top; width:90px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">DOB</span></p>
</td>
<td style="vertical-align:top; width:217px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:83px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:83px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">Yes</span></p>
</td>
<td style="vertical-align:top; width:71px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">Yes</span></p>
</td>
<td style="vertical-align:top; width:65px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">Yes</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:51px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">7</span></p>
</td>
<td style="vertical-align:top; width:71px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">DOB Precision</span></p>
</td>
<td style="vertical-align:top; width:106px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">mst_Patient </span></p>
</td>
<td style="vertical-align:top; width:90px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">DobPrecision</span></p>
</td>
<td style="vertical-align:top; width:217px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">Flag in database</span></p>
</td>
<td style="vertical-align:top; width:83px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:83px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:71px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:65px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:51px; height:105px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">6</span></p>
</td>
<td style="vertical-align:top; width:71px; height:105px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">Age</span></p>
</td>
<td style="vertical-align:top; width:106px; height:105px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">Calculated</span></p>
</td>
<td style="vertical-align:top; width:90px; height:105px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:217px; height:105px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">This field represents the current age of the patient and will change over time if the form is pulled up.</span><br />
<span style="font-size: 8pt;">Ages less than one year should be displayed as a decimal. For example, if a patient is 6 months old it should display as .5 years.</span></p>
</td>
<td style="vertical-align:top; width:83px; height:105px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:83px; height:105px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:71px; height:105px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:65px; height:105px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">Yes</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:51px; height:120px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">6</span></p>
</td>
<td style="vertical-align:top; width:71px; height:120px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">Age at Enrollment (years)</span></p>
</td>
<td style="vertical-align:top; width:106px; height:120px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">Calculated</span></p>
</td>
<td style="vertical-align:top; width:90px; height:120px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:217px; height:120px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">The age on the enrollement form reprsesents the age of the pateint when they enrolled and should not change over time.</span><br />
<span style="font-size: 8pt;">Ages less than one year should be displayed as a decimal. For example, if a patient is 6 months old it should display as .5 years.</span></p>
</td>
<td style="vertical-align:top; width:83px; height:120px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:83px; height:120px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:71px; height:120px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:65px; height:120px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:51px; height:75px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">new</span></p>
</td>
<td style="vertical-align:top; width:71px; height:75px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">Transfer in</span></p>
</td>
<td style="vertical-align:top; width:106px; height:75px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:90px; height:75px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">Transfer in</span></p>
</td>
<td style="vertical-align:top; width:217px; height:75px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">This is &nbsp;a checkbox that indicates that the patient has transferred in from another location. If this is selected, a select list for LPTF transferred from displays</span></p>
</td>
<td style="vertical-align:top; width:83px; height:75px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:83px; height:75px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:71px; height:75px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:65px; height:75px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:51px; height:60px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">new</span></p>
</td>
<td style="vertical-align:top; width:71px; height:60px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">LPTF Transfer from</span></p>
</td>
<td style="vertical-align:top; width:106px; height:60px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:90px; height:60px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">LPTF Transferred from</span></p>
</td>
<td style="vertical-align:top; width:217px; height:60px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">This field needs to be filled in if checkbox for Transfer in is selected. The list comes from the Patient Transfer custom list.</span></p>
</td>
<td style="vertical-align:top; width:83px; height:60px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:83px; height:60px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:71px; height:60px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:65px; height:60px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:51px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">8</span></p>
</td>
<td style="vertical-align:top; width:71px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">Chief/Local council</span></p>
</td>
<td style="vertical-align:top; width:106px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">mst_Patient </span></p>
</td>
<td style="vertical-align:top; width:90px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">LocalCouncil</span></p>
</td>
<td style="vertical-align:top; width:217px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:83px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">Yes</span></p>
</td>
<td style="vertical-align:top; width:83px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:71px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:65px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:51px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">8</span></p>
</td>
<td style="vertical-align:top; width:71px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">Village/Town/City name</span></p>
</td>
<td style="vertical-align:top; width:106px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">mst_Patient </span></p>
</td>
<td style="vertical-align:top; width:90px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">VillageName</span></p>
</td>
<td style="vertical-align:top; width:217px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">Custom list</span></p>
</td>
<td style="vertical-align:top; width:83px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">Yes</span></p>
</td>
<td style="vertical-align:top; width:83px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:71px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:65px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:51px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">8</span></p>
</td>
<td style="vertical-align:top; width:71px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">District/County/ Ward</span></p>
</td>
<td style="vertical-align:top; width:106px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">mst_Patient </span></p>
</td>
<td style="vertical-align:top; width:90px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">DistrictName</span></p>
</td>
<td style="vertical-align:top; width:217px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">Custom list</span></p>
</td>
<td style="vertical-align:top; width:83px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">Yes</span></p>
</td>
<td style="vertical-align:top; width:83px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:71px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:65px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:51px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">8</span></p>
</td>
<td style="vertical-align:top; width:71px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">Province/ State</span></p>
</td>
<td style="vertical-align:top; width:106px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">mst_Patient </span></p>
</td>
<td style="vertical-align:top; width:90px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">Province</span></p>
</td>
<td style="vertical-align:top; width:217px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">Custom list</span></p>
</td>
<td style="vertical-align:top; width:83px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">Yes</span></p>
</td>
<td style="vertical-align:top; width:83px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:71px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:65px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:51px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">8</span></p>
</td>
<td style="vertical-align:top; width:71px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">Residence/Address/PO Box</span></p>
</td>
<td style="vertical-align:top; width:106px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">mst_Patient </span></p>
</td>
<td style="vertical-align:top; width:90px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">Address</span></p>
</td>
<td style="vertical-align:top; width:217px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:83px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">Yes</span></p>
</td>
<td style="vertical-align:top; width:83px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:71px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:65px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:51px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">8</span></p>
</td>
<td style="vertical-align:top; width:71px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">Phone number</span></p>
</td>
<td style="vertical-align:top; width:106px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">mst_Patient </span></p>
</td>
<td style="vertical-align:top; width:90px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">Phone</span></p>
</td>
<td style="vertical-align:top; width:217px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:83px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">Yes</span></p>
</td>
<td style="vertical-align:top; width:83px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:71px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:65px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:51px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">9</span></p>
</td>
<td style="vertical-align:top; width:71px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">Emergency Contact Name</span></p>
</td>
<td style="vertical-align:top; width:106px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">dtl_PatientContacts</span></p>
</td>
<td style="vertical-align:top; width:90px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">EmergContactName</span></p>
</td>
<td style="vertical-align:top; width:217px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:83px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">Yes</span></p>
</td>
<td style="vertical-align:top; width:83px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:71px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:65px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:51px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">9</span></p>
</td>
<td style="vertical-align:top; width:71px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">Emergency Contact Relationship</span></p>
</td>
<td style="vertical-align:top; width:106px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">dtl_PatientContacts</span></p>
</td>
<td style="vertical-align:top; width:90px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">EmergContactRelation</span></p>
</td>
<td style="vertical-align:top; width:217px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:83px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:83px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:71px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:65px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:51px; height:90px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">9</span></p>
</td>
<td style="vertical-align:top; width:71px; height:90px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">Emergency Contact Phone Number</span></p>
</td>
<td style="vertical-align:top; width:106px; height:90px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">dtl_PatientContacts</span></p>
</td>
<td style="vertical-align:top; width:90px; height:90px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">EmergContactPhone</span></p>
</td>
<td style="vertical-align:top; width:217px; height:90px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">This information is taken on the Enrollment form and should be presented again in the Contact &amp; Care Tracking form, with the label &quot;Guardian Contact Informaiton&quot; </span><br />
<span style="font-size: 8pt;">Field to remove for de-identified export</span></p>
</td>
<td style="vertical-align:top; width:83px; height:90px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">Yes</span></p>
</td>
<td style="vertical-align:top; width:83px; height:90px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:71px; height:90px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:65px; height:90px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:51px; height:60px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">9</span></p>
</td>
<td style="vertical-align:top; width:71px; height:60px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">Emergency Contact Address</span><br />
<span style="font-size: 8pt;">Field to remove for de-identified export</span></p>
</td>
<td style="vertical-align:top; width:106px; height:60px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">dtl_PatientContacts</span></p>
</td>
<td style="vertical-align:top; width:90px; height:60px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">EmergContactAddress</span></p>
</td>
<td style="vertical-align:top; width:217px; height:60px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:83px; height:60px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">Yes</span></p>
</td>
<td style="vertical-align:top; width:83px; height:60px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:71px; height:60px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:65px; height:60px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:51px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">10</span></p>
</td>
<td style="vertical-align:top; width:71px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">Does contact person know your HIV status?</span></p>
</td>
<td style="vertical-align:top; width:106px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">dtl_PatientContacts</span></p>
</td>
<td style="vertical-align:top; width:90px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">EmergContactKnowsHIVStatus</span></p>
</td>
<td style="vertical-align:top; width:217px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:83px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:83px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:71px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:65px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:51px; height:45px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">11</span></p>
</td>
<td style="vertical-align:top; width:71px; height:45px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">If no, can we discuss your status with this contact person?</span></p>
</td>
<td style="vertical-align:top; width:106px; height:45px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">dtl_PatientContacts</span></p>
</td>
<td style="vertical-align:top; width:90px; height:45px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">DiscussStatus</span></p>
</td>
<td style="vertical-align:top; width:217px; height:45px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:83px; height:45px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:83px; height:45px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:71px; height:45px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:65px; height:45px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:51px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">12</span></p>
</td>
<td style="vertical-align:top; width:71px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">Marital status</span></p>
</td>
<td style="vertical-align:top; width:106px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">mst_Patient </span></p>
</td>
<td style="vertical-align:top; width:90px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">MaritalStatus</span></p>
</td>
<td style="vertical-align:top; width:217px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">Custom select box; Comes from the Marital Status Master</span></p>
</td>
<td style="vertical-align:top; width:83px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:83px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:71px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:65px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:51px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">13</span></p>
</td>
<td style="vertical-align:top; width:71px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">Educational Level</span></p>
</td>
<td style="vertical-align:top; width:106px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">mst_Patient </span></p>
</td>
<td style="vertical-align:top; width:90px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">EducationLevel</span></p>
</td>
<td style="vertical-align:top; width:217px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">Custom select box; Comes from the Education Master</span></p>
</td>
<td style="vertical-align:top; width:83px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:83px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:71px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:65px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:51px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">14</span></p>
</td>
<td style="vertical-align:top; width:71px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">Literacy</span></p>
</td>
<td style="vertical-align:top; width:106px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">mst_Patient </span></p>
</td>
<td style="vertical-align:top; width:90px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">Literacy</span></p>
</td>
<td style="vertical-align:top; width:217px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:83px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:83px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:71px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:65px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:51px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:71px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:106px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:90px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:217px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:83px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:83px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:71px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:65px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:51px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">15</span></p>
</td>
<td style="vertical-align:top; width:71px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">Have you ever received care for HIV/AIDS?</span></p>
</td>
<td style="vertical-align:top; width:106px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">dtl_HIVAidsCareTypes</span></p>
</td>
<td style="vertical-align:top; width:90px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">PrevHIVCare</span></p>
</td>
<td style="vertical-align:top; width:217px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:83px; height:30px; padding:4px; border:solid 1px #000000;"><br />
</td>
<td style="vertical-align:top; width:83px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:71px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:65px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:51px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">15</span></p>
</td>
<td style="vertical-align:top; width:71px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">If yes, specify type</span></p>
</td>
<td style="vertical-align:top; width:106px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">dtl_PatientHivPrevCareEnrollment </span></p>
</td>
<td style="vertical-align:top; width:90px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">list of previous care types</span></p>
</td>
<td style="vertical-align:top; width:217px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:83px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:83px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:71px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:65px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:51px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">15</span></p>
</td>
<td style="vertical-align:top; width:71px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">Previous HIV Care - Other</span></p>
</td>
<td style="vertical-align:top; width:106px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">dtl_PatientHivPrevCareEnrollment </span></p>
</td>
<td style="vertical-align:top; width:90px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">prevHIVTypeOther</span></p>
</td>
<td style="vertical-align:top; width:217px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:83px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:83px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:71px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:65px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:51px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">16</span></p>
</td>
<td style="vertical-align:top; width:71px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">Have you ever been on ARTs?</span></p>
</td>
<td style="vertical-align:top; width:106px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">dtl_PatientHivPrevCareEnrollment </span></p>
</td>
<td style="vertical-align:top; width:90px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">PrevART</span></p>
</td>
<td style="vertical-align:top; width:217px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:83px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:83px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:71px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">Yes</span></p>
</td>
<td style="vertical-align:top; width:65px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:51px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">16</span></p>
</td>
<td style="vertical-align:top; width:71px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">If yes, specify sponsor</span></p>
</td>
<td style="vertical-align:top; width:106px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">dtl_PatientHivPrevCareEnrollment </span></p>
</td>
<td style="vertical-align:top; width:90px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">list of sponsors</span></p>
</td>
<td style="vertical-align:top; width:217px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:83px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:83px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:71px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:65px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:51px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">16</span></p>
</td>
<td style="vertical-align:top; width:71px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">Previous ARTs Sponsor Other</span></p>
</td>
<td style="vertical-align:top; width:106px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">dtl_PatientHivPrevCareEnrollment </span></p>
</td>
<td style="vertical-align:top; width:90px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">PrevARTSOtherSpecs</span></p>
</td>
<td style="vertical-align:top; width:217px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:83px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:83px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:71px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:65px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:51px; height:60px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">16a</span></p>
</td>
<td style="vertical-align:top; width:71px; height:60px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">If yes, can we have a copy of your medical records today?</span></p>
</td>
<td style="vertical-align:top; width:106px; height:60px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">dtl_PatientHivPrevCareEnrollment </span></p>
</td>
<td style="vertical-align:top; width:90px; height:60px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">PrevMedRecords</span></p>
</td>
<td style="vertical-align:top; width:217px; height:60px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:83px; height:60px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:83px; height:60px; padding:4px; border:solid 1px #000000;"><br />
</td>
<td style="vertical-align:top; width:71px; height:60px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">Yes, If &quot;Have you ever been on ART&quot; = Yes</span></p>
</td>
<td style="vertical-align:top; width:65px; height:60px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:51px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:71px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:106px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:90px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:217px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:83px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:83px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:71px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:65px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:51px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">17</span></p>
</td>
<td style="vertical-align:top; width:71px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">Employment status</span></p>
</td>
<td style="vertical-align:top; width:106px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">dtl_PatientHouseHoldInfo</span></p>
</td>
<td style="vertical-align:top; width:90px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">EmploymentStatus</span></p>
</td>
<td style="vertical-align:top; width:217px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:83px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:83px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:71px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:65px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:51px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">17</span></p>
</td>
<td style="vertical-align:top; width:71px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">Occupation</span></p>
</td>
<td style="vertical-align:top; width:106px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">dtl_PatientHouseHoldInfo</span></p>
</td>
<td style="vertical-align:top; width:90px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">Occupation</span></p>
</td>
<td style="vertical-align:top; width:217px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:83px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:83px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:71px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:65px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:51px; height:45px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">18</span></p>
</td>
<td style="vertical-align:top; width:71px; height:45px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">Monthly Income</span></p>
</td>
<td style="vertical-align:top; width:106px; height:45px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">dtl_PatientHouseHoldInfo</span></p>
</td>
<td style="vertical-align:top; width:90px; height:45px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">MonthlyIncome</span></p>
</td>
<td style="vertical-align:top; width:217px; height:45px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">Show currency label (as per configuration) and add commas and decimals</span></p>
</td>
<td style="vertical-align:top; width:83px; height:45px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:83px; height:45px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:71px; height:45px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:65px; height:45px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:51px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">19</span></p>
</td>
<td style="vertical-align:top; width:71px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">How many children do you have?</span></p>
</td>
<td style="vertical-align:top; width:106px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">dtl_PatientHouseHoldInfo</span></p>
</td>
<td style="vertical-align:top; width:90px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">NumChildren</span></p>
</td>
<td style="vertical-align:top; width:217px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:83px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:83px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:71px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:65px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:51px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">20</span></p>
</td>
<td style="vertical-align:top; width:71px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">How many people are in your household?</span></p>
</td>
<td style="vertical-align:top; width:106px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">dtl_PatientHouseHoldInfo</span></p>
</td>
<td style="vertical-align:top; width:90px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">NumPeopleHousehold</span></p>
</td>
<td style="vertical-align:top; width:217px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:83px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:83px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:71px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:65px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:51px; height:45px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">21</span></p>
</td>
<td style="vertical-align:top; width:71px; height:45px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">Distance travelled from residence to point of service</span></p>
</td>
<td style="vertical-align:top; width:106px; height:45px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">dtl_PatientHouseHoldInfo</span></p>
</td>
<td style="vertical-align:top; width:90px; height:45px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">DistanceTravelled</span></p>
</td>
<td style="vertical-align:top; width:217px; height:45px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:83px; height:45px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:83px; height:45px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:71px; height:45px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:65px; height:45px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:51px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">22</span></p>
</td>
<td style="vertical-align:top; width:71px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">How long did it take you to get here today? Time</span></p>
</td>
<td style="vertical-align:top; width:106px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">dtl_PatientHouseHoldInfo</span></p>
</td>
<td style="vertical-align:top; width:90px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">TimeTravelled</span></p>
</td>
<td style="vertical-align:top; width:217px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:83px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:83px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:71px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:65px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:51px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">22</span></p>
</td>
<td style="vertical-align:top; width:71px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">How long did it take you to get here today? Units</span></p>
</td>
<td style="vertical-align:top; width:106px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">dtl_PatientHouseHoldInfo</span></p>
</td>
<td style="vertical-align:top; width:90px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">TravelledUnits</span></p>
</td>
<td style="vertical-align:top; width:217px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">Days, Hours, Minutes</span></p>
</td>
<td style="vertical-align:top; width:83px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:83px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:71px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:65px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:51px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:71px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:106px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:90px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:217px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:83px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:83px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:71px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:65px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:51px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">24</span></p>
</td>
<td style="vertical-align:top; width:71px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">HIV Status</span></p>
</td>
<td style="vertical-align:top; width:106px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">dtl_PatientHivOther </span></p>
</td>
<td style="vertical-align:top; width:90px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">HIVStatus</span></p>
</td>
<td style="vertical-align:top; width:217px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:83px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:83px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:71px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:65px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:51px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">25</span></p>
</td>
<td style="vertical-align:top; width:71px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">HIV disclosure status</span></p>
</td>
<td style="vertical-align:top; width:106px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">dtl_PatientHivOther </span></p>
</td>
<td style="vertical-align:top; width:90px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">HIVDisclosure</span></p>
</td>
<td style="vertical-align:top; width:217px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:83px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:83px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:71px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:65px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:51px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">25</span></p>
</td>
<td style="vertical-align:top; width:71px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">HIV disclosure status Other</span></p>
</td>
<td style="vertical-align:top; width:106px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">dtl_PatientHivOther </span></p>
</td>
<td style="vertical-align:top; width:90px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">HIVDisclosureOther</span></p>
</td>
<td style="vertical-align:top; width:217px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:83px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:83px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:71px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:65px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:51px; height:60px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">26</span></p>
</td>
<td style="vertical-align:top; width:71px; height:60px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">How many member(s) of your household do you know have done an &nbsp;HIV Test?</span></p>
</td>
<td style="vertical-align:top; width:106px; height:60px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">dtl_PatientHivOther </span></p>
</td>
<td style="vertical-align:top; width:90px; height:60px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">NumHouseholdHIVTest</span></p>
</td>
<td style="vertical-align:top; width:217px; height:60px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:83px; height:60px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:83px; height:60px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:71px; height:60px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:65px; height:60px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:51px; height:60px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">26b</span></p>
</td>
<td style="vertical-align:top; width:71px; height:60px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">How many member(s) of your household do you know have tested positive for HIV ?</span></p>
</td>
<td style="vertical-align:top; width:106px; height:60px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">dtl_PatientHivOther </span></p>
</td>
<td style="vertical-align:top; width:90px; height:60px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">NumHouseholdHIVPositive</span></p>
</td>
<td style="vertical-align:top; width:217px; height:60px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:83px; height:60px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:83px; height:60px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:71px; height:60px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:65px; height:60px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:51px; height:60px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">27</span></p>
</td>
<td style="vertical-align:top; width:71px; height:60px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">How many member(s) of your household do you know are deceased from HIV? </span></p>
</td>
<td style="vertical-align:top; width:106px; height:60px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">dtl_PatientHivOther </span></p>
</td>
<td style="vertical-align:top; width:90px; height:60px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">NumHouseholdHIVDied</span></p>
</td>
<td style="vertical-align:top; width:217px; height:60px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:83px; height:60px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:83px; height:60px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:71px; height:60px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:65px; height:60px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:51px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">28</span></p>
</td>
<td style="vertical-align:top; width:71px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">Membership in HIV support group</span></p>
</td>
<td style="vertical-align:top; width:106px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">dtl_PatientHivOther </span></p>
</td>
<td style="vertical-align:top; width:90px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">SupportGroup</span></p>
</td>
<td style="vertical-align:top; width:217px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:83px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:83px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:71px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:65px; height:30px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:51px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">28</span></p>
</td>
<td style="vertical-align:top; width:71px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">If yes, specify</span></p>
</td>
<td style="vertical-align:top; width:106px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">dtl_PatientHivOther </span></p>
</td>
<td style="vertical-align:top; width:90px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">SupportGroupName</span></p>
</td>
<td style="vertical-align:top; width:217px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:83px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:83px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:71px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:65px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:51px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:71px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:106px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:90px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:217px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:83px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:83px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:71px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:65px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:51px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">29</span></p>
</td>
<td style="vertical-align:top; width:71px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">Patient Referred from:</span></p>
</td>
<td style="vertical-align:top; width:106px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">mst_Patient</span></p>
</td>
<td style="vertical-align:top; width:90px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">ReferredFrom</span></p>
</td>
<td style="vertical-align:top; width:217px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:83px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:83px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:71px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:65px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:51px; height:11px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:71px; height:11px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">Potential Barriers to successful HIV care</span></p>
</td>
<td style="vertical-align:top; width:106px; height:11px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">dtl_PatientHivOther </span></p>
</td>
<td style="vertical-align:top; width:90px; height:11px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">List of barriers (BarrierFinancial, BarrierFearDisclosure, etc.)</span></p>
</td>
<td style="vertical-align:top; width:217px; height:11px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:83px; height:11px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:83px; height:11px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:71px; height:11px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:65px; height:11px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:51px; height:37px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:71px; height:37px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">Potential Barriers to successful HIV care - Notes</span></p>
</td>
<td style="vertical-align:top; width:106px; height:37px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">dtl_PatientHivOther</span></p>
</td>
<td style="vertical-align:top; width:90px; height:37px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:217px; height:37px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:83px; height:37px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:83px; height:37px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:71px; height:37px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:65px; height:37px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:51px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:71px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:106px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:90px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:217px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:83px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:83px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:71px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:65px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:51px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:71px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">Interviewer</span></p>
</td>
<td style="vertical-align:top; width:106px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">mst_Patient</span></p>
</td>
<td style="vertical-align:top; width:90px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">EmployeeID</span></p>
</td>
<td style="vertical-align:top; width:217px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:83px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:83px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:71px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:65px; height:15px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:51px; height:60px; padding:4px; border:solid 1px #000000;"><br />
</td>
<td style="vertical-align:top; width:71px; height:60px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">Print</span></p>
</td>
<td style="vertical-align:top; width:106px; height:60px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:90px; height:60px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">Print</span></p>
</td>
<td style="vertical-align:top; width:217px; height:60px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;">This button is used to make a hard copy of the form. This is basically feature of paperless, but is implemented for non paperless too</span></p>
</td>
<td style="vertical-align:top; width:83px; height:60px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:83px; height:60px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:71px; height:60px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
<td style="vertical-align:top; width:65px; height:60px; padding:4px; border:solid 1px #000000;"><p><span style="font-size: 8pt;"> </span></p>
</td>
</tr>
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